Hysterectomy

Topic Overview

A hysterectomy is surgery to take out a
woman's uterus, the organ in a woman's belly where a baby grows during
pregnancy. After a hysterectomy, you will not be able to get pregnant.

Other organs might also be removed if you have severe problems such as
endometriosis or cancer. These organs include the
cervix (the lower part of the uterus that opens into
the vagina), the
ovaries (glands on both sides of the uterus that
release eggs for pregnancy), and the
fallopian tubes (the passageway between the uterus and
the ovaries).

Whether or not the ovaries are removed will depend
on your age and risk for certain types of cancer. For example, removing the
ovaries lowers the risk of ovarian cancer and some types of breast cancer. But
if you have your ovaries removed before the age of menopause, you will go into
early menopause, and you may be more likely to get heart disease or
osteoporosis. Be sure to discuss with your doctor all the benefits and risks of
removing your ovaries.

What problems does this surgery treat?

Most often,
hysterectomy is done to treat problems with the uterus, such as pain and heavy
bleeding caused by
endometriosis or
fibroid tumors. The surgery may also be needed if
there is cancer in the uterus, cervix, or ovaries. Some women may have the
surgery during childbirth to save their lives if there is heavy bleeding that
cannot be stopped.

Before you choose to have a hysterectomy,
consider all of your treatment options. In many cases, this surgery is a last
resort after trying other treatments for the problem.

How is the surgery done?

There are many different
ways to do hysterectomy surgery. The type of surgery you have depends on three
main things: the reason for the surgery, the size of the uterus and its
position in the belly, and your overall health. The most common types
are:

Abdominal hysterectomy. In this type, the
doctor makes a cut in the belly, either across the bikini line or straight up
and down. The doctor takes out the uterus and the cervix. This type is most
often done when cancer might be present or when severe endometriosis, a lot of
scar tissue (adhesions), or a very large uterus makes the uterus
hard to remove.

Vaginal hysterectomy. With this type, the doctor
takes out the uterus through the vagina. He or she makes a small cut in the
vagina instead of the belly. Your doctor will not use this method when there is
a chance that cancer may be in the uterus, cervix, or ovaries. Doctors use this
type of surgery only in cases where the uterus is small and easy to remove.

Laparoscopically assisted vaginal hysterectomy (LAVH). To do this
surgery, the doctor puts a lighted tube (laparoscope)
through small cuts in your belly. The doctor can see your organs with the scope
and can insert surgical tools to cut the tissue that holds your uterus in
place. Then he or she can remove the uterus through your vagina.

Laparoscopic supracervical hysterectomy (LSH). With LSH, the
doctor inserts the scope and tools through small cuts in your belly. He or she
takes out the uterus in small pieces and leaves the cervix in place.

Total laparoscopic
hysterectomy (TLH). In this type, the doctor inserts a scope and tools through
several small cuts in the belly. The doctor takes out the uterus and the cervix
in small pieces through one of the cuts.

How long will it take to recover from surgery?

Feeling better after surgery takes time. Most women are in the hospital 1
or 2 days after the surgery. Some women stay in the hospital up to 4 days.

When you get home, make sure you move around, but also be sure
you don't do too much. You can walk around the house and up and down stairs,
but take it slow. During the first 2 weeks, it's important to get plenty of
rest. Even after you start to feel stronger, you should not lift heavy things
(anything over 20 pounds). Also, you should not have sex until your doctor says
it's okay. It usually takes 4 to 8 weeks to get back to a normal routine.

Why It Is Done

In most cases,
hysterectomy is an elective surgery used to treat
noncancerous
female reproductive system (gynecologic) conditions that haven't improved with
medical treatment. For women who have no plans for pregnancy and have
considered and tried other treatment options without success, a hysterectomy
may be a reasonable treatment choice.

Total hysterectomy is
the surgical removal of the uterus and the
cervix, which is the lower "neck" of the uterus that
opens into the vagina.

Subtotal hysterectomy is the removal of the uterus, leaving the cervix in place.
It is also known as "supracervical" or "partial" hysterectomy.

Radical hysterectomy is the removal of the
uterus, cervix, ovaries, structures that support the uterus, and sometimes the
lymph nodes. A radical hysterectomy may be done to
treat
endometriosis or cancer of the uterus, ovaries, or
cervix.

Deciding whether to have a total or subtotal hysterectomy
can be difficult. This is because research that compares the two is limited and
shows only small differences. In the past, experts believed that a subtotal
hysterectomy reduced problems after surgery and prevented problems with urinary
incontinence and/or sexual dysfunction. But research has shown that for certain
conditions, a subtotal hysterectomy does not prevent these problems better than
a total hysterectomy does.1

When
considering a hysterectomy,
ask your doctor what other treatments can be used for your condition, what hysterectomy
options are available to you, and how well hysterectomy is likely to work for
you. If you have a hysterectomy, the type of procedure you have will depend on
the medical reason for the hysterectomy, the size and position of your uterus,
and your general state of health.

Comparison of Hysterectomy Procedures

There are
several different
hysterectomy procedures, each with advantages and
disadvantages. Depending on your reason for considering a hysterectomy, you may
have a choice between two or more procedures. For complicated or cancer-related
conditions that require maximum access and careful examination, your doctor
will likely recommend an abdominal hysterectomy.

Vaginal hysterectomy

This type of hysterectomy is
done through a small incision in the
vagina, rather than through an abdominal incision. The
ovaries and other organs may also be removed. Vaginal
hysterectomy tends to cause less pain, and takes less healing time than
abdominal hysterectomy. A vaginal hysterectomy can be done:

When there is no significant scarring in the pelvis from previous surgeries.

Vaginal hysterectomy requires more specialized surgical
skill than an abdominal hysterectomy. It can pose a higher risk of injury to
other organs. Vaginal hysterectomy is not used when there is a question about
possible cancer in the uterus,
cervix, or ovaries.

Abdominal hysterectomy

This type of hysterectomy
is done through a larger abdominal incision, giving the surgeon the best
possible access to the pelvic organs. The cervix may be removed with the uterus
(total hysterectomy) or left in place (subtotal hysterectomy). The
ovaries and other organs may also be removed. An
abdominal hysterectomy is typically done when:

The uterus is very large.

Uterine
fibroids are larger than
8 in. (20 cm) across or located
around blood vessels.

Cancer of the uterus, ovaries, or
cervix is possible.

An ovarian growth (mass) is suspected but can't be diagnosed on
ultrasound.

There is significant scarring or severe endometriosis
in the pelvic area.

If a hysterectomy is chosen to treat endometriosis, an
abdominal hysterectomy is usually required. One example is when endometriosis
growths (implants) or scar tissue (adhesions) must be removed to restore the
function of other organs.

Laparoscopically assisted vaginal hysterectomy (LAVH)

Laparoscopic hysterectomy is done with a viewing instrument (laparoscope)
and surgical instruments inserted through a vaginal incision and one or more
small abdominal incisions. The ovaries and other organs may also be removed.
The uterus is removed through the vagina. It is done:

To assess or remove ovaries at
the same time as a vaginal hysterectomy.

LAVH requires the surgeon to have
specialized training.

Laparoscopic supracervical hysterectomy (LSH)

Laparoscopic supracervical hysterectomy is done by
inserting a laparoscope and surgical instruments through several small
abdominal incisions. The uterus is removed in small pieces through one of the
incisions and the cervix is left intact. This is also known as subtotal or partial
hysterectomy. This type of procedure usually causes minimal blood loss and
pain. The hospital stay is shorter than for total abdominal surgery. Most women
can return to normal activity a week or two afterward. LSH can be done:

To remove uterine fibroids of any
size.

To remove a uterus of any size.

LSH usually takes longer to do than abdominal or vaginal hysterectomy. LSH is
not available in some areas.

Total laparoscopic hysterectomy (TLH)

The total laparoscopic hysterectomy is done by
inserting a laparoscope and surgical instruments through several small
incisions in the abdomen. The uterus and the cervix are removed in small pieces
through one of the incisions. TLH can be done:

To remove uterine fibroids that are small to
moderate in size.

When there is not a lot of scar tissue in the
pelvic area.

When there is not a worry about cancer in the
ovaries.

TLH requires the surgeon to have
special training. It usually takes longer to do than abdominal or vaginal
hysterectomy. But recovery and hospital stay are shorter than for total
abdominal hysterectomy. TLH is not available in many parts of the
country.

Advantages and disadvantages of hysterectomy procedures

Procedure

Advantages

Disadvantages

Vaginal hysterectomy

Enables removal of a normal to slightly
larger-than-normal uterus and small
uterine fibroids

When compared with abdominal
hysterectomy, requires a shorter hospital stay2

When compared with abdominal
hysterectomy, requires a shorter hospital stay, with a faster and less painful
recovery

Leaves smaller scars on the abdomen than with an abdominal
hysterectomy

When compared with other types of
hysterectomy, a routine LSH:

May need to be switched to an abdominal
surgery if the doctor is unable to remove a very large uterus or areas of
endometriosis,
adenomyosis, or scar tissue (adhesions).

Is likely to cost more.

May have an increased risk of injury if the surgeon is
inexperienced.

Total laparoscopic hysterectomy (TLH)

Does not use an incision in the wall of
the vagina

When compared with abdominal hysterectomy, requires a
shorter hospital stay, with a faster and less painful
recovery

Leaves smaller scars on the abdomen than with an abdominal
hysterectomy

When compared with other types of
hysterectomy, a routine TLH:

May need to be switched to an abdominal
surgery if the doctor is unable to remove a very large uterus or areas of
endometriosis,
adenomyosis, or scar tissue (adhesions).

Is likely to cost more.

Risks of Hysterectomy

Hysterectomy
poses some risks of major and minor complications. But most women do not have
complications after a hysterectomy.

Some studies have shown
complication rates that are about the same for total laparoscopic hysterectomy
(TLH), laparoscopically assisted vaginal hysterectomy (LAVH), and total
abdominal hysterectomy (TAH).4, 5 Your risk of problems after surgery may be higher or lower
than average. This may depend in part on how experienced the surgeon is.

Major medical complications after hysterectomy

Rates of major complications after vaginal
hysterectomy and abdominal hysterectomy (rounded to nearest 0.5%):3

Collection of blood (hematoma) at the surgery site
needing surgical drainage

1%

1%

At least one major complication

9.5%

6%

In the study described above, the major complication
rate was nearly twice as high after laparoscopic abdominal hysterectomies than after open abdominal hysterectomies. Complication rates were about the same for vaginal and
laparoscopic vaginal surgeries. (These rates do not apply to radical
hysterectomy done to treat cancer.)3

Collection of blood (hematoma) at the surgery site
not needing surgical drainage

6%

6%

At least one minor complication

28%

27%

In the study described above, there was no significant
difference in minor complication rates, whether the hysterectomy was
laparoscopic, vaginal, or abdominal. (These rates do not apply to radical
hysterectomy done to treat cancer.)

Infection risk is lowest when
your doctor gives you
antibiotic medicine at the time of surgery.6

Other ongoing complications of hysterectomy
include:

Difficulty urinating. This is more common
after removal of
lymph nodes,
ovaries, and structures that support the uterus
(radical hysterectomy).

Weakness of the pelvic muscles and
ligaments that support the vagina, bladder, and rectum.
Kegel exercises may help strengthen the pelvic muscles
and ligaments. But some women need other treatments, including additional
surgery.

Continued
heavy bleeding. Some vaginal bleeding within 4 to 6
weeks following a hysterectomy is expected. But call your doctor if bleeding
continues to be heavy.

A meeting with the
doctor who will do the hysterectomy. During this meeting, the doctor will
explain how the surgery will be done, where the
surgical incisions will be made, and the risks and
expected outcomes of the surgery. You will probably receive written
instructions about how to prepare for surgery at this time.

A
meeting with an
anesthesiologist or nurse anesthetist. During this
meeting, you will discuss the
types of anesthetic recommended for use during the
surgery. You may not meet with this person until the day of your
surgery.

Your doctor may order additional tests based on your
physical exam and medical history. These tests may include:

When to Call a Doctor

After a
hysterectomy, call your doctor or go to the emergency
room if:

You have bright red vaginal bleeding that soaks
one or more pads in an hour, or you have large clots.

You have
foul-smelling discharge from your vagina.

You are sick to your
stomach or cannot keep fluids down.

You have signs of infection, such as:

Increased pain, swelling, warmth, or
redness.

Red streaks leading from the incision.

Pus
draining from the incision.

Swollen lymph nodes in your neck,
armpits, or groin.

A fever.

You have pain that does not get better after you take pain
medicine.

You have loose stitches, or your incision comes
open.

You have signs of a blood clot, such as:

Pain in your calf, back of knee, thigh, or
groin.

Redness and swelling in your leg or groin.

You have trouble passing urine or stool,
especially if you have pain or swelling in your lower belly.

You
have hot flashes, sweating, flushing, or a fast or pounding heartbeat.

Your doctor will give you specific instructions after your
hysterectomy. Be sure to follow them. Usually, getting some rest and following
those instructions will help postoperative problems diminish over time.

Recovery

Recovering from a
hysterectomy takes time. You will stay in the hospital
for 1 to 2 days for postsurgery care. Some women stay in the hospital up to 4
days.

Abdominal hysterectomy. As soon as
you feel strong enough, get up and around as much as you can. This helps
prevent problems after surgery like blood clots, pneumonia, and gas pains.
During the first 2 to 3 weeks, it is important to also get plenty of rest. Hold a pillow over your incision when you cough or take deep breaths. This will support your belly and decrease your pain.

You
will gradually be able to increase your activities. To help you heal well,
avoid lifting more than 20 pounds during the first 4 to 6 weeks after surgery.
For the same reason, this is also an important time to avoid vaginal
intercourse.

As soon as you can move easily without pain or
without using narcotic pain medicine, you can drive. Complete recovery usually
takes 4 to 8 weeks. Your return to a work routine will depend not only on how
quickly you get back your energy and strength but also on how demanding your
work is.

Vaginal or laparoscopic hysterectomy. As soon as you feel strong enough, get up and around as
much as you can. This helps prevent problems after surgery like blood clots,
pneumonia, and gas pains. When you can move easily without pain, you can drive.
To help you heal well, avoid lifting more than 20 pounds during the first 4 to
6 weeks after surgery. For the same reason, this is also an important time to
avoid vaginal intercourse.

Recovery from a vaginal or
laparoscopic hysterectomy takes much less time than from an abdominal surgery.
After a routine laparoscopic surgery removing the
uterus but not the
cervix (laparoscopic supracervical hysterectomy, or
LSH), most women are able to return to normal activity in 1 to 2 weeks. About 4
to 6 weeks after the hysterectomy, see your doctor for a follow-up
examination.

What are possible long-term problems after hysterectomy?

Pelvic weakness. After a hysterectomy, some women
develop other physical problems that are related to weakness of the pelvic
muscles and ligaments that support the vagina, bladder, and rectum.
Kegel exercises may help strengthen the pelvic muscles
and ligaments. But some women need other treatments, including additional
surgery.

Vaginal dryness from low estrogen
levels may develop if your ovaries were removed (oophorectomy). This can also
develop gradually after a hysterectomy. If sexual intercourse is painful
because of vaginal dryness:

Use a vaginal lubricant, such as K-Y Jelly
or Astroglide, or a polyunsaturated vegetable oil that does not contain
preservatives. If you are using condoms, use a water-based lubricant, rather
than an oil-based lubricant. Oil can weaken the condom so that it breaks. Avoid
petroleum jelly (for example, Vaseline) as a lubricant, because it increases the
risk of vaginal irritation and infection.

Pain during intercourse may occur if
your vagina was shortened during your hysterectomy. Changing positions may help
make intercourse less painful. Talk with your doctor if you have any difficulty
during intercourse after a hysterectomy.

How will I feel emotionally after my hysterectomy?

It is normal to have various
concerns when faced with the possibility of having a
hysterectomy. A woman's emotions are often based on her
beliefs about the importance of her uterus, her fears
about her health or personal relationships after a hysterectomy, and concerns
about her
enjoyment of sexual activities after surgery. If you
are considering a hysterectomy, talk with your doctor about your specific fears
and anxieties concerning the surgery.

What to Think About

Your doctor may suggest
other treatments before recommending a hysterectomy. If you are considering a
hysterectomy and would like more information about other treatments or
surgeries, talk with your doctor. Ask about the risks and benefits of each
option. Consider both the immediate and long-term risks and benefits of all
treatments.

Hysterectomy is a necessary and effective treatment
for cancer of the pelvic organs, a severe infection of the uterus, or
uncontrollable bleeding.

Following hysterectomy, you will not be
able to become pregnant. If you have plans for a future pregnancy, hysterectomy
is not an appropriate treatment option for conditions such as
uterine fibroids,
endometriosis, or
pelvic organ prolapse. Talk with your doctor about
other treatments.

Hysterectomy is not used to prevent pregnancy.
There are many methods of birth control that are safe and effective. If you are
not sure which method is best for you, talk with your doctor about your
options.

Estrogen therapy (ET)

Women who have
early, sudden menopause after hysterectomy are usually advised to use
estrogen therapy (ET) to protect against
bone loss. The low estrogen levels of menopause cause bone thinning. Compared
with women who are not taking hormone therapy, women taking ERT have fewer hip
fractures (a sign of estrogen's bone-protecting effect).7

American Congress of Obstetricians and Gynecologists
(ACOG) is a nonprofit organization of professionals who provide health care for
women, including teens. The ACOG Resource Center publishes manuals and patient
education materials. The Web publications section of the site has patient
education pamphlets on many women's health topics, including reproductive
health, breast-feeding, violence, and quitting smoking.

International Premature Ovarian Failure
Association

P.O. Box 23643

Alexandria, VA 22304

Phone:

(703) 913-4787

Web Address:

www.pofsupport.org

This organization offers support for women who have
entered menopause early. The organization offers information, referrals, phone
support, and literature.

National Women's Health Network

514 10th Street NW

Suite 400

Washington, DC 20004

Phone:

(202) 347-1140

Fax:

(202) 347-1168

Email:

nwhn@nwhn.org

Web Address:

www.womenshealthnetwork.org/

This nonprofit advocacy group includes consumers, health
centers, and organizations. The National Women's Health Network monitors
federal health policy and operates an information clearinghouse.

Office on Women's Health

Department of Health and Human Services

200 Independence Avenue, SW Room 712E

Washington, DC 20201

Phone:

1-800-994-9662(202) 690-7650

Fax:

(202) 205-2631

TDD:

1-888-220-5446

Web Address:

www.womenshealth.gov

The Office on Women's Health is a service of the U.S. Department of Health and Human Services. It provides women's health information to a variety of
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